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32 | Regarding the allegation, neglect of care and supervision that resulted in the resident’s condition requiring medical intervention, the investigation revealed the following: R1 was admitted to the facility in the memory care unit on October 18, 2024, and was placed on hospice on October 2, 2024, prior to moving into the facility. R1 has a diagnosis of Senile Degeneration of the Brain, Atrial Fibrillation, and high blood pressure. R1 required full assistance such as transfers, escorting, and toileting per the Needs and Services Plan dated October 18, 2024. Per interviews conducted, four out of nine staff reported that the status checks were conducted every two hours and more if resident is a fall risk. The service plan notes R1 not requiring additional status checks although the facility staff were informed R1 routinely getting up at least two to three times to use the bathroom in the middle of the night at the time. Staff #2 (S2) was informed of the night routine during the pre-appraisal assessment conducted at R1’s home on October 7, 2024 at 3pm.
On November 9, 2024, at approximately 8:03am, a caregiver discovered R1 in a prone position suspended from the bed rail by the neck. Per medical reports on page 200, dated November 9, 2024, R1 had sustained an unwitnessed fall in the evening, however the time of fall and the exact length of time R1 was suspended is unknown. During the investigation, it was determined that that residents are assigned to staff for monitoring. Staff #4 (S4) was assigned to check on R1 every 2 hours. S4 stated that they checked R1 at 2:30am on November 9th. Based on S4’s statement, S4 admitted not following the facility policy requiring them to check on the resident every two hours. The facility staff did not document the checks, and there was no way to verify that the checks were actually completed.
After discovering R1 suspended, the caregiver notified Staff #1 (S1) reporting a “headlock,” and S1 arrived at the room at about 8:07am. S1 immediately attempted to reach Staff #2 (S2) by phone three times but was unsuccessful and subsequently called Staff #3 (S3) via FaceTime to report the incident. S3 instructed S1 not to move R1 and to call 911 instead. Paramedics arrived approximately 8:34am and discovered R1 in the same position, while the staff, instead of freeing the resident, were observed clearing the live ants from R1’s face, mouth, and body. Emergency Medical Services (EMS) reported that R1’s airway had been obstructed by the rail causing R1’s oxygen levels to drop and their face and neck to swell. Page 68 of the medical report dated November 10, 2024, confirms R1’s oxygen saturation was at 81% at the time of assessment and improved to 93% after R1 was placed on a non-rebreather mask. |